REGISTRATION FORM

14th Continuing Professional Development (CPD) Series:

7th Diabetes Complications Conference & Grand Rounds March 27-29, 2015

Hotel Istana, Kuala Lumpur, MALAYSIA

Please type or print your particulars in BLOCK letters.

Name: Prof/Dr/Mr/Mrs/Ms

Family Name/ Surname (If any):

Organisation: Mailing Address:

Postcode: State: Country:

Telephone (Off): (M):

Fax: E-mail:

Name to appear on conference certificate:

Name to appear on conference name tag:

Meals: Normal Vegetarian

Conference & Grand Rounds Venue:

Hotel Istana73 Jalan Raja Chulan50200 Kuala Lumpur

MALAYSIA

7th Diabetes Complications Conference & Grand Rounds Fees

EARLY BIRD REGISTRATIONbefore January 31, 2015

(Please tick)AFTER January 31, 2015

(Please tick)

International Local** International Local**

REGISTRATION

Delegate

Paramedic / Allied Health

Post Graduate Student*

USD450

USD350

USD350

RM650

RM600

RM600

USD550

USD450

USD450

RM750

RM700

RM700

* Official endorsement from institution is required**Subsidised rates

Cancellation & Transfer

If you are unable to attend, a replacement participant is allowed at no extra cost provided written notice is given prior to the Conference & Grand Rounds.

A 90% refund can be made for cancellation received in writing or by fax at least 4 weeks before the Conference & Grand Rounds.

A 50% refund will be given if cancellation is received 14 days before the Conference & Grand Rounds.

Mode of Payment^^

I enclosed herewith Crossed Cheque/Bank Draft/Money Order/Local Order^^

(No. ) of USD/RM

______________________ _____________________ Signature Date

^ Crossed Cheque/Bank Draft/Money Order/Postal Order/Local Order should be made payable to the National Diabetes Institute.

^^ Payments made through Crossed Cheque/Bank Draft/Money Order/Local Order should be sent directly with the registration form to the Conference & Grand Rounds Secretariat.

Secretariat Address:

National Diabetes Institute (NADI)No.1, Jalan SS3/5047300 Petaling JayaSelangor, MALAYSIA

Email: enquiry@nadidiabetes.com.myWebsite: diabetesmalaysia.com.my

Tel: 603 - 7876 1676 / 1677 Fax: 603 7876 1679

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